Episode Details

This show was one of the most popular episodes in the past 12 months, so enjoy this encore while I am in Chicago moderating a panel on pharmacy benefit management at the WTW Conference Board.

But while I have you, I just wanted to thank everyone for listening. You really are a part of our Relentless Tribe, and I could not thank you enough for your commitment to doing the right thing for patients and for this country—and that dedication is evidenced by you listening as often as you do to Relentless Health Value. Our show has the largest following of individuals who are truly pushing hard for patients over profits, and since, according to LinkedIn anyway, 40% of our listeners are at the "highest level of seniority in their organization," I'm guessing that we have the muscle to do this thing. Thanks for being part of the Relentless Tribe and for all that you do.

In this healthcare podcast, I'm talking with Brian Klepper. If you haven't heard of him, Brian's a longtime healthcare analyst and former CEO of the National Business Coalition on Health.

This interview takes off like a shot, as most of my conversations with Brian Klepper do. We're talking about primary care and its various iterations. We start out with Exhibit A—the HMO version of primary care from the '90s. This is a great comparator to really get a handle on what's going on today. During the heyday of HMOs (back in the '90s), primary care was basically a glorified gatekeeper kind of doing two things. On one hand, they were restricting access. It wasn't an accident that it was really hard to get an appointment with a PCP.

On the other hand, it also wasn't an accident that, once you got there, the PCP only had 7 minutes to spend with you, which basically meant that you left with an appointment to see a specialist at, of course, the health system that probably had just bought that PCP practice. Everybody's happy then, right?

Specialist volume goes up, they make a ton of money for the health system, plans make a ton of money because they make a percentage of total healthcare spend … Oh right, everybody's happy except the patient who can't get care and the PCP who can't do their job.

By the way, for more information on why the '90s version of the HMO industry crashed and burned, listen to my conversation with Alex Jung on this exact topic. A big part of the "why" really actually took me by surprise.

But back to primary care … Today, in broad strokes, we have three kinds of PCPs. And when I say three kinds of PCPs, we're not really counting urgent cares or what amounts to urgent cares in that mix—meaning, not counting a lot of the retail clinics because they don't really manage patient care like you'd hope a PCP would manage care. Last I checked, none of them were managing much more than an episodic visit. You can't manage a chronic condition in 15 minutes.

So, like I said, there's three kinds of PCPs that are around today; and let's call the first kind the original PCP. This version of the PCP office is primarily fee for service (FFS). Maybe they have a couple of capitated contracts. But the distinguishing factor isn't really what their payer mix is. It's that they're not taking on much risk or any risk of real consequence.

Second, we have direct primary care doctors. This group tends to cut out insurers and work directly with either employers or patients themselves. They take a monthly fee, and, in general, a patient can see them however much they need to. Again, no risk or little risk is assumed here beyond the primary care services themselves that are rendered.

Third, we have what Brian calls industrialized primary care—or some people call it advanced primary care, or APC—but I'd probably call it something different. I'd call it "taking risk for the full continuum of care" primary care. Maybe I wouldn't even